Fowler, Mary NEW YORK STATE DEPARTMENT OF HEALTH '' 44
Vital Records Section Burial - Transit rmit
_' Name First Middle Last 1 Sex
Mary M. Fowler Female
Date of Death Age If Veteran of U.S. Armed Forces,
: August 16,2012 90 War or Dates No
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death a Natural Cause n Accident n Homicide n Suicide Undetermined 1-1 Pending
W Circumstances Investigation
Medical Certifier Name Title
LS Bernardo R.Villajuan Dr.
Address
88 Broad St,Glens Falls,NY 12804
Death Certificate Filed 1 District Number Register Number
:F City, Town or Village Queensbury ! 5657 fy
❑Burial Date Cemetery or Crematory
❑Entombment August 18,2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date 1 Place Removed
Z Removal 1 and/or Held
and/or Address
N Hold
O I Date Point of
N n Transportation Shipment
p by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
' , Permit Issued to Registration Number
`, Name of Funeral Home Regan& Denny Stafford Funeral Home 1 01443
Address
? 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Z Address
re
to
• Permission is hereby granted to dispose of the human re i s described bove s indicated.
Date Issued -/7-1cv i-. Registrar of Vital Statistics - ' _
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition tit-it Place of Disposition (UktJ Crt4ri
W (address)
co
CC (section) / - (lot number) , (grave number)
pName of Sexton or Person in Charge of Premises A,I r Jtwviit-
Z Z.,1111L
(please print)
Signature , A Title Cganiw :(dQ
(over)
DOH-1555(02/2004)